Club Sessions Registration Form - (For Participants)

Enrollment Interest Form

Part of Club Sessions Enrollment
Participants Name

First NameLast Name
Participants Phone Number*
Please enter a valid phone number.
Participants Email*
example@example.com
Gender

MaleFemalePrefer not to sayOther
Participants ability to use a computer?

Has difficulty using a computerCan perform basic functions (e.g., turning on the computer, opening applications)Comfortable using common applications and the internetVery proficient with many software applicationsOther
List any Skills, Hobbies or Interests Below That You Would Like To Share
Developmental Considerations
Select Any Autism Spectrum Diagnosis Below

Autism DisorderPervasive Developmental Disorder - Not Otherwise Specified (PDD-NOS)Attention Deficit Hyperactivity Disorder (ADHD)NonePrefer Not To SayOther
What would you like to gain during your experience / enrollment in Club Sessions?
I affirm that I am the person listed above and have answered the questions in this survey to the best of my knowledge and understanding.
Participants Age*
Printed Name
Signature*

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Enrollment Interest Form